How Ventilation Is Delivered During Cardiopulmonary Resuscitation: an International Survey

RESPIRATORY CARE Paper in Press. Published on May 8, 2018 as DOI: 10.4187/respcare.05964

How Ventilation Is Delivered During Cardiopulmonary Resuscitation: An International Survey

Ricardo Luiz Cordioli MD PhD, Laurent Brochard MD, Laurent Suppan MD, Aissam Lyazidi PhD, Franc¸ois Templier MD, Abdo Khoury MD, Stephane Delisle RRT PhD, Dominique Savary MD, and Jean-Christophe Richard MD PhD

BACKGROUND: Recommendations regarding ventilation during cardiopulmonary resuscitation (CPR) are based on a low level of scientific evidence. We hypothesized that practices about ventilation during CPR might be heterogeneous and may differ worldwide. To address this question, we surveyed physicians from several countries on their practices during CPR. METHODS: We used a Web-based opinion survey. Links to the survey were sent by e-mail newsletters and displayed on the Web sites of medical societies involved in CPR practice from December 2013 to March 2014. RESULTS: 1,328 surveys were opened, and 548 were completed (41%). Responses came from 54 countries, but 64% came from 6 countries. Responders were mostly physicians (89%). From this group, 97% declared following specific CPR guidelines. Regarding practices, 28% declared always or frequently adopting only continuous chest compressions without additional ventilation. With regard to mechanical chest compression devices, 38% responded that such devices were available to them; when used, 28% declared always or frequently experiencing problems with ventilation such as frequent alarms. During bag-mask ventilation in intubated patients, 18% declared stopping chest compression during insufflation, and 39% applied > 10 breaths/min, which conflicts with international CPR guidelines. When a ventilator was used, the volume controlled mode was the most common strategy cited, but there was heterogeneity regarding ventilator settings for PEEP, trigger, F , and breathing IO2 frequency. S and end-tidal CO were the 2 most monitored variables cited. CONCLUSIONS: pO2 2 Physicians indicated heterogeneous practices that often differ significantly from international CPR guidelines. This may reflect the low level of evidence and a lack of detailed recommendations concerning ventilation during CPR. Key words: ventilation; cardiac arrest; cardiopulmonary resuscitation; mechanical chest compression; manual chest compression; chest compression; survey; practices. [Respir Care 0;0(0):1–•. © 0 Daedalus Enterprises]

Introduction because it can interfere with chest compressions. Recom- mendations regarding ventilation during CPR in CPR guide- The ventilatory strategy used during cardiopulmonary lines are weak and are based on relatively low levels of resuscitation (CPR) could influence the chance of survival evidence.1-4

Dr Cordioli is affiliated with Hospital Israelita Albert Einstein, Intensive Matie´re et Instrumentation, Universite´Hassan 1er, Settat, Morocco. Dr Care Unit, Sao Paulo, Brazil, and Hospital Alemaõ Oswaldo Cruz, In- Templier is affiliated with University Hospital of Angers, SAMU 49, tensive Care Unit, Sao Paulo, Brazil. Dr Brochard is affiliated with the Emergency Department, Angers, France. Dr Khoury is affiliated with Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s University Hospital of Besançon, Besançon, France. Dr Delisle is affil- Hospital, Toronto, Canada, and the Interdepartmental Division of Critical iated with Hoˆpital du Sacre´-Cœur de Montreál, Service des Soins Inten- Care Medicine, University of Toronto, Toronto, Ontario, Canada. Dr sifs, Que´bec, Canada. Drs Savary and Richard are affiliated with General Suppan is affiliated with Geneva University Hospitals, Division of Emer- Hospital of Annecy, SAMU 74 and Emergency Department, Annecy, gency Medicine, Geneva, Switzerland. Dr Lyazidi is affiliated with In- France. Dr Richard is also affiliated with INSERM UMR 955 Eq13 stitut Supe´rieur des Sciences de la Sante´, Laboratory Rayonnement- Cre´teil, France.

RESPIRATORY CARE • ●●VOL ● NO ● 1 Copyright (C) 2018 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE RESPIRATORY CARE Paper in Press. Published on May 8, 2018 as DOI: 10.4187/respcare.05964

INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

In the past, ventilation was the first action to be adopted during CPR.5,6 All guidelines published between 1974 and QUICK LOOK 2005 advocated the famous ABC sequence (A, airway; B, Current knowledge breathing and C, circulation) during the rescue of a victim Assisted ventilation is an important aspect of cardio- of cardiac arrest (see the supplementary material at http:// pulmonary resuscitation (CPR) because it can directly www.rcjournal.com). The importance of ventilation de- influence survival through positive or negative interac- creased progressively in these guidelines over time,7 and the international CPR guidelines published in 2010 changed tions with chest compression. International guidelines, however, are supported by a low level of evidence and the former ABC sequence to CAB.1-4 Some authors advocate only performing chest compres- practice heterogeneity is expected. sions during CPR, without ventilation, with the goal to What this paper contributes to our knowledge provide better neurological outcomes. This strategy is advocated for the general public. Once at least 2 health care This survey showed that practices regarding the com- professionals are involved, airway opening and breathing bination of assisted ventilation with chest compressions should be performed according to international CPR guide- during CPR were heterogeneous and often differed sig- lines.1-4 Physiological interactions between ventilation and nificantly from CPR guidelines. Difficulties related to circulation may also differ when chest compression is done ventilation were reported to be high. manually or with automated devices. Due to a lack of sufficient evidence in the literature, clinicians are often left with doubts about how ventilation should be performed.9-11 Heterogeneity of ventilation prac- regions in France with experience in CPR. A subsequent draft tices during CPR is therefore likely to occur. Because questionnaire underwent a review process by 20 physicians ventilation practices may affect outcomes, we conducted who participated in the acute respiratory failure meeting group an international survey to assess opinions regarding the or the trauma and emergency medicine meeting group during practices specifically related to ventilation during CPR in the 2013 European Society of Intensive Care Medicine Con- adult victims of a non-traumatic cardiac arrest. gress in Paris, France. The final version (see the supplementary material at http://www.rcjournal) was hosted on a Web Methods platform (http://www.cardiomobile.ch), and several physicians from different regions in France tested it. Instrument Survey responses were closed, and response options varied, including multiple choice, single choice on a 4-point response We used a mixed-methods approach to develop our ques- scale (never, rarely, frequently, or always), and Yes/No an- tionnaire, taking into account the current international CPR swers. Some questions were only available depending on guidelines.1-4 The first version of our questionnaire was specific answers related to accessibility or practices. created after discussion among 3 critical care physicians This survey was voluntary and anonymous, and addi- working in Europe, 1 physician in Brazil, and 2 emergency tional consent was not required according to Swiss regu- department physicians in Switzerland. We intentionally latory rules. sampled participants to represent different practice settings. We developed a draft questionnaire, which we pi- Subjects loted among a focus group of 5 physicians from different Professionals involved in resuscitation teams, including physicians, nurses, respiratory therapists, and paramedics, were considered as potential responders about the way Dr Richard has disclosed relationships with Air Liquide Medical Sys- they manage ventilation and chest compression in adult tems, Vygon, Dra¨ger, and Covidien. Dr Brochard has disclosed relationships with Maquet, Covidien, Dra¨ger, Philips Respironics, Air Liquide, victims of a non-traumatic cardiac arrest. and General Electric. Dr Khoury has disclosed a relationship with the European Commission. Survey Administration

Supplementary material related to this paper is available at http:// www.rcjournal.com. An invitation was sent to members of different national or European societies involved in CPR, and a link to the Correspondence: Ricardo Luiz Cordioli MD PhD, Hospital Israelita Al- self-administered survey was available on the Web sites of bert Einstein, Av Albert Einstein, 627 - Morumbi 05652-900, Sao Paulo, Brazil. E-mail: [email protected]. these societies. The survey could be completed from De- cember 2013 to March 2014. A reminder invitation was DOI: 10.4187/respcare.05964 sent twice during this period.

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

Analysis device was higher (97 respondents, 44%) as well as the probability to use it, according to 60% (58 respondents) Only fully completed surveys were analyzed. We elected who preferred using mechanical chest compression de- a priori to include only those respondents who reported vice over manual chest compression. being clinically active in performing CPR. Practices and Organization Results General. Almost all physicians (475 of 490 respondents, Survey Participation 97%) declared following specific CPR guidelines; 73% (11 of 15 respondents) of those who did not follow a CPR Of the 1,328 surveys opened, 548 (41%) were com- guideline belonged to a non-university hospital. The Euro- pleted. Responses came from 54 countries, but most an- pean Resuscitation Council guidelines were the most cited swers (64%) came from 6 countries: France (25%), Japan (232 of 475 respondents, 49%), followed by the American (14%), Brazil (11%), Belgium (9%), and Canada (5%). Heart Association guidelines (38%) and national guidelines (11%); hospital-specific protocols were scarcely cited (2%). Respondents Basic Life Support. Among the physicians who com- The great majority of responders were physicians (490 of pleted the survey, 28% (138 of 490 respondents) answered 548 respondents, 89%), while nurses (40, 7%), paramedics always or frequently adopting the strategy of only contin- (11, 2%), and respiratory/physical therapists (7, 1%) repre- uous chest compression without any additional form of sented a small proportion coming from only 3 countries. We ventilation, especially at the beginning of resuscitation thus decided to analyze only physicians’ responses (n ϭ 490) when the rescuer is alone. for more consistency and representativeness. For non-intubated patients, when CPR was performed with In this group, 55% (270 of 490 physician respondents) an automated chest compression device (LUCAS/AutoPulse), worked in a university hospital, 35% (170 respondents) 68% (103 of 152 respondents) declared always or frequently declared having a clinical activity in the pre-hospital emer- applying the 30:2 option to ventilate the patient with a bag- gency field, and 54% (265 respondents) said they had mask device; when a supraglottic airway was inserted (eg, some activity in the ICU setting. laryngeal mask airway), only 36% of the physicians (55 of 152 respondents) answered always or frequently applying the Equipment Available for Ventilation and Chest 30:2 option to ventilate the patient. Compression During Intubation Procedure. During the intubation Almost all physicians (479 of 490 respondents, 98%) procedure, 46% of all respondents (225 of 490 respon- affirmed having a bag-mask, which was cited to be the dents) and 43% of physicians (65 of 152 physician respon- only device available by 19% (94 respondents); 74% (363 dents) who declared having an automated mechanical chest respondents) declared having a ventilator, and 7% (33 re- compression device available confirmed stopping manual spondents) said they had a Boussignac CPR tube (Vygon, or mechanical chest compression, respectively. Ecouen, France) available for CPR. Concerning chest compression, 38% (186 of 490 re- Advanced Life Support. In patients already intubated, spondents) declared having a specific external pump 68% of the physicians (326 of 479 respondents) de- mechanical device; 24% (116 respondents) declared hav- clared never stopping manual chest compression for bag- ing a piston chest compression (LUCAS-CPR, Physio mask insufflation. Of these 326 respondents, 48% (158) Control, Lund, Sweden; or Thumper Mechanical CPR declared adopting a frequency of 8–10 insufflations/min, 5% device, Michigan Instruments, Michigan); 12% (61 re- (16) declared using a frequency Ͻ 8 insufflations/min, spodents) had an automated load-distributing band (Auto- 37% (121) declared using a frequency Ͼ 10 insuffla- Pulse, Zoll, Chelmsford), and 2% (9 respondents) tions/min; of the 121 who used a frequency Ͼ 10 in- answered that they had a manual mechanical chest com- sufflations/min, 20% (24) used a frequency Ն 16 insuf- pression device available (AMBU CardioPump, AMBU flations/min. Company, Copenhagen, Denmark). Finally, 7% (32 re- During manual chest compression in patients already spondents) said they had Ͼ 1 mechanical device avail- intubated, 87% (428 of 490 respondents) and 46% (223 of able for chest compression. A total of 211 physicians 490 respondents) declared always or frequently using a (43%) declared belonging to a center engaged in non- bag-mask and a ventilator, respectively. Continuous flow heart-beating organ donation. In this subgroup, the avail- insufflation with the Boussignac tube specific to CPR was ability of an automatic mechanical chest compression cited by only 4% (18 of 490 respondents).

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

60 A 40

20 Proportion (%) 0 0 1 to 5 6 to 10 > 10 Ventilator’s default Depends on the situation PEEP (cm H2O)

60 B 40

20 Proportion (%) 0 < 8 8 to 10 11 to 15 > 16 Ventilator’s Depends default on the Breathing frequency (breaths/min) situation

60 C 40

20 Proportion (%) 0 ON OFF Ventilator’s default Depends on the Trigger situation Fig. 1. Ventilator settings during cardiopulmonary resuscitation.

Ventilator Settings and Monitoring. When a ventilator declared always or frequently applying the 30:2 option; was applied during CPR, the volume controlled mode was 62% (94 of 152) and 57% (86 of 152) of the physicians the most commonly cited mode (260 of 363 respondents, declared always or frequently using a bag-mask and a 72%), followed by pressure controlled mode (85 of 363, ventilator, respectively; 12% (18 of 152) of the partic- 23%), and CPAP (18 of 363, 5%). ipants who had an automatic mechanical chest compres- There was a marked heterogeneity regarding the ven- sion device available changed their ventilation monitor- tilator settings of PEEP values (Fig. 1A), breathing fre- ing options when using these devices instead of manual quency (Fig. 1B), and trigger (Fig. 1C). Among re- chest compression. In addition, 32% (48 of 152 physi- sponders who had a ventilator available, 42% (153 of cians) cited always or frequently changing their venti- 363 respondents) declared setting F according to pulse IO2 lation practice when using an automated chest compres- oximetry (S ), with heterogeneous S targets (Fig. pO2 pO2 sion device: 72% (35 of 48) of them declared adjusting 2A). Among those who declared setting F indepen- IO2 ventilator settings, 36% (18 of 48) switched from man- dently of S , almost all cited an F of 1.0 (Fig. 2B). pO2 IO2 ual to mechanical ventilation, and 21% (10 of 48) Monitoring practices were also heterogeneous, with S pO2 switched from mechanical to manual ventilation (more and end-tidal CO2 being the 2 most frequently cited than one answer was possible). variables (Fig. 3). Finally, only 27% (41 of 152 physicians) declared never experiencing major problems (Fig. 4A) concerning venti- Specific Settings for Automatic Chest Compression De- lation when automated chest compression devices were vices. During automatic mechanical chest compression used. Different strategies were proposed to face major in intubated patients, 18% (28 of 152) of the physicians problems (Fig. 4B).

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

35 A 30

10 Proportion (%)

0 90 92 94 96 ≥ 98 S pO2

100 B 80

40 Proportion (%) 20

0 < 5050 to 80 81 to 99 100 F IO2 Fig. 2. F during cardiopulmonary resuscitation. (A) According to S target. (B) Independent of S value. IO2 pO2 pO2

Discussion having a mechanical device dedicated to chest compression. A systemic review comparing manual and mechan- This is the first international survey evaluating opin- ical chest compression concluded that mechanical chest ions and declared practices regarding ventilation during compression was not associated with harm or benefit.13 In CPR. The results suggest a wide heterogeneity in prac- situations such as during transportation, in the catheteriza- tices exist. Based on the results of our survey, we can tion laboratory, and as a bridge to more invasive support, distinguish 2 major findings. First, regarding ventila- mechanical chest compression seems to be an interesting tion, there is a gap between declared practices and CPR option, as well as when high-quality manual chest com- recommendations in international guidelines. These ob- pression cannot be delivered.14We hypothesize that auto- servations are consistent with results of an observa- matic chest compression may render ventilation more dif- tional study analyzing the quality of multiple parame- ficult and thus interfere with clinical practices; there are ters of CPR12 and showing that practices often do not few studies regarding the best ventilation strategy associ- align with published recommendations. Second, although ated with mechanical chest compression devices, and our nearly all of the respondents stated that they follow survey showed that the occurrence of ventilation problems international guidelines, responses from the physicians is not negligible when this method of chest compression is who completed the survey were heterogeneous. Both used. findings could reflect the low level of evidence and the lack of specificity in the recommendations for ventila- Ventilation and Chest Compression tion during CPR. Interestingly, more than a quarter of respondents de- Available Equipment for CPR clared adopting only continuous chest compression, high- For ventilation, a bag-mask was the most common de- lighting the prioritization of chest compression over as- vice available, while less than half of responders answered sisted ventilation.15-17 Some authors advocate that

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

Other

None

Exhaled minute volume

Plateau pressure

Peak inspiratory pressure

Tidal volume

Clinical assessment of chest rise

Blood gases

P ETCO2

S pO2

0 20 40 60 80 100 Proportion (%) Fig. 3. Monitoring of ventilation-related variables during cardiopulmonary resuscitation. P ϭ end-tidal carbon dioxide pressure. ETCO2 ventilation is not necessary during the early phase18 or The optimal timing of an advanced airway placement is when the rescuer is alone because providing assisted ven- not well defined in the literature. Some studies demon- tilation may decrease the effectiveness of CPR by increas- strated positive results when subjects were intubated22 in ing the time without chest compression.19 the first 13 min,23 while other studies showed better results Nichol et al20 published a trial in 2015 in which adults when endotracheal intubation was avoided24 or delayed in receiving CPR were treated with continuous chest com- favor of minimally interrupted chest compression.25 Rec- pression with asynchronous ventilations delivered at a rate ommendations regarding the relationship between chest of 10 ventilations/min (intervention group) or with inter- compression and ventilation were not strictly followed by rupted chest compression for ventilation at a ratio of 30:2, almost 20% of the providers, regardless of whether the respectively (control group). The rate of survival to hos- patient was intubated. pital discharge and favorable neurologic function at discharge were similar in both groups. Interestingly, the chest- Ventilation Practice compression fraction, which is an important marker of interruptions of chest compression, were high in both groups More than 80% of the responders declared having more (0.77 in intervention group and 0.83 in control group) and than one option to support ventilation during CPR, which above international recommendations. The mechanics driv- implies that understanding the different features of each ing blood flow during CPR are complex and positive- device is important. Despite the various risks in relation to pressure ventilation may play a key role in promoting the use of a bag-mask,26,27 this device remains the most better blood flow along with chest compressions if the widely used to deliver assisted ventilation during CPR. interaction between ventilation and chest compression is Hyperventilation can be common during CPR. In the por- well adjusted.21 cine CPR model, a higher ventilation rate promotes a lower We observed that almost half of the providers declared coronary perfusion pressure and survival rate.28 Interna- stopping chest compression for endotracheal intubation. tional guidelines recommend 8–10 breaths/min when the

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

Other

High tidal volume

High CO2

Low CO2

Pulmonary edema

Hemoptysis

Volume alarm

Low tidal volume

Pressure alarm

0 20 40 60 80 100 Proportion (%)

Other

Return to manual chest compression

Change the ventilatory settings

Return to manual bag ventilation

020406080 Proportion (%) Fig. 4. Ventilation during cardiopulmonary resuscitation done with an automated chest compression device. (A) Major problems experi- enced. (B) Different strategies proposed to face major problems. patient is already intubated, but we observed that almost 40% oxygenation target may carry specific risks, but further of the rescuers adopted a ventilation rate Ͼ 10 breaths/min studies are needed to define the appropriate level of when using a bag-mask device. oxygenation during CPR. Our results indicated a large heterogeneity in setting ventilator parameters during CPR, possibly reflecting Monitoring the absence of detailed recommendations in guidelines. Furthermore, a controversy exists regarding the use of In this study, the most frequently monitored parameter positive-pressure ventilation,29,30 which could explain was S . End-tidal CO was the second most cited pa- pO2 2 the different PEEP practices observed in this survey. rameter to be monitored, despite numerous limitations that Regarding oxygenation, the current literature is equiv- render its use in routine practice complex.34 Nevertheless, ocal; some studies have demonstrated that hyperoxemia end-tidal CO2 is usually considered as a physiological pa- is associated with higher mortality,31,32 whereas a large rameter that correlates with cardiac output and reflects the retrospective study did not find any relationship.33 In quality of chest compression during CPR.7,35 The Euro- our survey, almost all of the providers established an pean Resuscitation Council’s 2015 guidelines highlighted F of 1.0 during CPR, and 35% declared adopting S the importance of end-tidal CO but limited its use to IO2 pO2 2 Ͼ 96% when using pulse oximetry as a target. This high specific purposes.36

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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

Manual Versus Automatic Mechanical Chest devices dedicated to either automated chest compression Compression and Ventilation or ventilation reported in this survey may also contribute to differences in the interpretation of guidelines. Ventilatory and monitoring practices were different when using an automatic mechanical chest compression device ACKNOWLEDGMENTS in comparison to manual chest compression. When using automatic mechanical chest compression devices, both the The authors are grateful to the European Society of Intensive Care Med- bag and a ventilator were frequently used. The occurrence icine, the French Society of Emergency Medicine (Socie´te´ Française de of ventilatory problems with automatic chest compression Me´decine d’Urgence), the Brazilian Association of Intensive Care Med- icine (Associaçaõ Brasileira de Medicina Intensiva), the French Lan- devices appears to be frequent because most of responders guage Society of Intensive Care (Socie´te´deReánimation de Langue declared experiencing majors issues requiring adjustment Française), the Japanese Society of Intensive Care Medicine, the Belgian of ventilator settings. Society of Intensive Care Medicine (Socie´te´ Belge d’Anesthe´sie et de Reánimation), the European Artificial Ventilation Research Network, the Ventilation Practices During CPR International PanArab Critical Care Medicine Society, the European Re- suscitation Council, and the European Critical Care Research Network- European Society of Intensive Care Medicine, who endorsed the survey. Gonza´lez et al,36 in a survey with questions similar to It was the survey of the month for the European Society of Intensive Care our survey, tried to describe ventilatory practice during Medicine in December 2013. We thank Nathalie Rey, Marc Niquille, and CPR in children. They observed, as in our adult survey, Evangelia Akoumianaki for their important contributions to the survey considerable variation in the management of ventilation formulation. for children in cardiac arrest, and international recommendations were not being followed in a high percentage of REFERENCES cases. The results of our survey, similar to those by Gonza´lez 1. Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Haz- 37 et al, suggest that further studies of the role of ventilation inski MF, et al. 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INTERNATIONAL SURVEY OF VENTILATION DELIVERY IN CPR

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